Physician experience is associated with the quality of care provided to HIV-positive patients, new research suggests. Investigators in New York State found that the patients of doctors treating fewer than 20 HIV-positive outpatients per year had sub-optimal antiretroviral treatment (ART) outcomes, and also received poor quality of care.
“We found that the majority of LVPs (low volume providers) practiced in primary care settings and were not infectious diseases specialists or identified as HIV specialists,” comment the authors.
In the US, physicians providing care to 20 or more HIV-positive outpatients in a year are classified as HIV specialists. HIV medicine is fast moving. Because of the pace of change in HIV prescribing and care guidelines, investigators in New York State wanted to see if HIV-positive outpatients who received their care from a doctor who prescribed ART to fewer than 20 individuals a year had sub-optimal therapeutic outcomes. The quality of patient clinical monitoring was also assessed.
The New York State Medicaid and AIDS Drug Assistance Program databases for 2009 were interrogated to identify physicians who prescribed ART to fewer than 20 patients. These providers were asked to provide details of their caseload and medical specialism. Physician performance was evaluated against national guidelines. Outcomes were virological suppression, frequency of clinical monitoring and screening for co-morbidities. The investigators compared the performance of low volume providers against those expected of more experienced HIV physicians.
A total of 368 low volume providers were identified. Their annual ART outpatient caseload ranged between 2-19 patients (mean 4.3). The most common physician specialities were internal medicine (41%), family medicine (31%) and infectious diseases (7%).
Additional practice details were provided by 209 (57%) doctors – 27 reported that they were involved in the co-management of ART-treated patients and 51 said they prescribed ART for reasons other than HIV – for instance the management of hepatitis B virus infection. Only four physicians identified as HIV specialists. However, others said they specialised in the care of HIV-positive women, pulmonary manifestations of HIV infection, or patients recently diagnosed with HIV.
Almost three-quarters of providers were located in New York City. Despite this, patients living outside New York City were more likely to be cared for by low volume providers (OR = 1.7; 95% CI, 1.4-1.9).
Viral load suppression rates were lower among the patients of low volume providers compared to the patients of more experienced doctors (56% vs. 77%, p < 0.01). The patients of low volume providers were also less likely to have regular viral load (44% vs. 90%) and CD4 monitoring (21% vs. 90%). They also had low rates of regular screening for syphilis (32% vs. 80%) and mental health problems (28% vs. 48%).
“Our study highlights the need to monitor data and trends in the HIV workforce,” conclude the authors. “Ongoing research is needed to examine strategies to guarantee a capable provider workforce for delivering effective care to HIV-positive patients over time and identify best practices.”
Background. Knowledge of care practices among clinicians who annually treat Methods. We communicated with 1278 (66%) of the LVPs identified through a statewide claims database to determine the circumstances under which they prescribed ART in federal fiscal year 2009. We reviewed patient records from 84 LVPs who prescribed ART routinely and compared their performance with that of experienced clinicians practicing in established HIV programs.
Results. Of the surveyed LVPs, 368 (29%) provided routine ambulatory care for 2323 persons living with HIV/AIDS, and 910 LVPs cited other reasons for prescribing ART. Although the majority of LVPs (73%) practices in New York City, patients living upstate were more likely to be cared for by a LVP (odds ratio, 1.7; 95% confidence interval, 1.4–1.9). Scores for basic HIV performance measures, including viral suppression, were significantly higher in established HIV programs than for providers who wrote prescriptions for prescribing ART. Although the majority of LVPs (73%) practices in New York City, patients living upstate were more likely to be cared for by a LVP (odds ratio, 1.7; 95% confidence interval, 1.4–1.9). Scores for basic HIV performance measures, including viral suppression, were significantly higher in established HIV programs than for providers who wrote prescriptions for <20 persons living with HIV/AIDS (P < .01). We estimate that 33% of New York State clinicians who provide ambulatory HIV care are LVPs.
Conclusions. Our findings suggest that the quality of care associated with providers who prescribe ART for <20 patients is lower than that provided by more experienced providers. Access to experienced providers as defined by patient volume is an important determinant of delivering high-quality care and should guide HIV workforce policy decisions.